How does expanding knowledge of population, community, and public health nursing improve the nurses practice?

CHAPTER 1 Populations as Clients By Sue Z. Green

We often think of nursing as giving meds on time, checking an X-ray to see if the doctor needs to be called, or taking an admission at 2:00 a.m. with a smile on our faces. Too often, we forget all the other things that make our job what it truly is: caring and having a desire to make a difference.Erin Pettengill (National CPR Association, n.d.)

Essential Questions ? How does expanding knowledge of population, community, and public health nursing

improve the nurses practice? ? What are expected competencies for the nurse practicing within population groups? ? How does the nurse apply the nursing process and collaborate with others to conduct a

populations health assessment? ? Which community resources are useful during planning and interventions for a

populations health?

Introduction Nursing care of ?populations? involves working with larger ?groups? of people and their corresponding multiple health care needs. Community and public health nurses consider the effect of ethnicity, culture, spiritual values, and geographic and socioeconomic conditions on the wellness of the population. Diverse populations have various ?health disparities? and health inequities? ?that? ?affect their ability to maintain health and meet health care needs. A greater understanding of historical and theoretical concepts provides a foundation for the nurses approach to care of populations. The role of the public health nurse and the essential function of public health services are explored in this chapter. The nursing process is applied as an

Population Health

? Population health? is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group? ?(Kindig & Stoddart, 2003, p. 381). Population health has a goal of measuring, intervening, and improving health disparities among groups, as well as the distribution of health, all of which is driven by assessment and statistical data. ?Public health?, a subcomponent of population health,? ?is the practice of protecting and promoting quality of life and holistic health of persons and communities through the use of science, research, and direct care. The American Public Health Association (APHA) defines ?public health nursing? as the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences (American Public Health Association [APHA], 2013, p. 2). Interdisciplinary public health practices aim to prevent disease outbreaks, injuries, and poor health while promoting cost-effective measures that improve quality of life and health as well as reduce environmental hazards (APHA, n.d.; Centers for Disease Control and Prevention Foundation, 2017).

Development of the Public Health Nursing Role

? Florence Nightingale initiated health visitors in 1892, a group composed of lay female missionaries with specialized training for instruction of health (Buhler-Wilkinson, 1985). Much of the focus was teaching women about caring for themselves and their children. This was the foundation of Englands district nursing today.

? Lillian Wald established the term ?public health nurse? with a focus on treating social and economic problems along with illness. In 1893, Wald and Mary Brewster put this belief into practice on the Lower East Side tenements of New York. Two years later, this led to the establishment of the Henry Street Settlement and, later, the development of the Visiting Nurses Association (VNA) (Fee & Bu, 2010).

? Mary Breckinridge introduced nurse midwifery to the United States in 1925. She traveled on horseback to deliver modern health care to the most inaccessible and poorest areas of Appalachia in Kentucky (Frontier Nursing Service, 2015). This lead to the subsequent development of the Frontier Nursing Service (FNS) and the expansion of public health nursing into remote rural areas (Frontier Nursing University, n.d.).

Policy Reform The public health profession continues to evolve. Various policy reforms in the United States have shaped public health nursing to become what it is today. Public health needs drive development of programs to improve public health. Sanitation reforms occurred as public health nursing emerged. Public health education, improved waste disposal methods, and clean-water policies reinforced the importance of the environment to the nations health. In 2004, a presidential order, signed by President George W. Bush, established the Office of National Coordinator for Health Information Technology, which included incentives for providers using health information technology (HIT), motivating them to utilize electronic medical records (Bush, 2004; DeSalvo, Dinkler, & Stevens, 2015). Timely and efficient access to patient-related information ushered in a new era of health informatics and population health. The 2010 Affordable Care Act (ACA) reinforced the importance of the use of HIT. Gradual transition of services to outpatient or community settings further reinforce the nurses role in population health management and health information technology.

From public health nursing, subspecialties have emerged, including school nursing, industrial and occupational health nursing, child health nursing, tuberculosis nursing, rural nursing, and the American Red Cross. Born from the rise of nursing specialty interest groups, the National Organization of Public Health Nursing (NOPHN) emerged with Lillian Wald as the first president. Many groups have since formed to address the varying needs of nurses across settings and clinical specialties, including the American Nurses Association (ANA). The ANA, the largest nursing organization, represents nurses across the United States, reinforcing the role of public health nursing. The ANA recognizes and promotes the Quad Council Coalition of Public Health Nursing Organizations (QCC or Quad Council) and public health nursings scope and standards of practice. The ANA also supports nursing involvement in public health advocacy, education, and policy, along with evolving health issues (American Nurses Association [ANA], n.d.).

Quad Council Coalition

The QCC comprises four nursing organizations serving public health nursing. Current

members include the Alliance of Nurses for Healthy Environments (ANHE), Public

Health Nursing Section of the American Public Health Association (PHN Section of

APHA), the Association of Community Health Nurse Educators (ACHNE), and the

Association of Public Health Nurses (APHN) (Quad Council Coalition of Public Health

Nursing Organizations [QCC], n.d.).

The QCC is the vehicle for guiding and developing current critical components and

competencies. Beginning in 2011, the QCC competencies were aligned to the ?Core

Competencies for Public Health Professions?, a guiding document the QCC developed to

bridge academic and public health practice (Public Health Foundation, n.d.; QCC, n.d.;

Swider, Krothe, Reyes, & Cavetz, 2013). This alignment provided a mechanism to

promote nursing evidence-based competencies congruent with other public health

professions and academic practices. The nursing competencies span three tiers of

practice over various skill domains with competencies. The three tiers categorize

practice as:

? Tier 1-basic or generalist ? Tier 2-specialist or midlevel ? Tier 3-executive and/or multi-systems level (Swider et al., 2013).

Those at the Tier 1 level work directly with the diverse populations to promote health

and prevent disease, collect and analyze data, plan programs, and conduct outreach

activities to reduce health disparities (QCC, n.d.). Tier 2 public health nurses are in

management or supervisory roles and assist in implementation of public health

programs (QCC, n.d.). Tier 3 competencies are for senior management or nurse

executive roles. Tier 3 public health nurses are responsible for administration,

organization, and operation of public health programs (QCC, n.d.).

Todays Community and Public Health Nurses

? Health promotion and care for the community and population at large reflect public/community health nurses mission, ?vision?, and ?commitments?. ?Community health nursing? and public health nursing are terms synonymous for the role of the nurse outside institutional settings; however, the terms are distinct from each other. Community health nursing has traditionally focused on nursing care for acute and chronic conditions outside the traditional hospital setting, primarily involving restorative care. Now, community health nursing involves health promotion of individuals and families, providing care in settings such as occupational or educational systems. Public health nursing addresses health promotion beyond an individuals or familys needs, incorporating community aspects and global or environmental concerns. Public health nursing focuses on groups, populations, or the health of an entire geographical sector (Canales & Drevdahl, 2014; Kulbok, Thatcher, Park, & Meszaros, 2012; Reifsnider & Garcia, 2015). Public health nursing is a ?population-focused? practice. This practice concentrates on the defined populations needs for prevention of illness and health improvement (Association of Public Health Nurses [APHN], n.d.; ANA, n.d.; APHA, 2013). A public health nurse (PHN) incorporates dynamics extending to small groups, or ?aggregates?, and beyond for improvement of a populations overall health. In turn, this improves the health of individuals and families living, employment, and recreational environments (Swider & Kulbok, 2015). Aggregates are persons who are grouped together because of common characteristics or location. The PHNs educational background is traditionally a baccalaureate or advanced practice level (Reifsnider & Garcia, 2015). To a nurse providing inpatient or primary care, a population means the patients who are within that setting, but for a PHN, the population is inclusive of the entire aggregate living in the community or a larger geographic sector. The PHNs population shares commonalities of disease and risk and, unlike patients in an inpatient setting, the population

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comprises all persons irrespective of whether they request services (Reifsnider & Garcia, 2015). Most nurses practice at individual and interpersonal levels of a community, but PHNs practice at the organizational, community, and public policy levels as well. The PHN collaborates with other disciplines and key community ?stakeholders?. These stakeholders are persons who are both involved and directly affected by the plans, actions, and outcomes of population health care. For example, stakeholders may be local government officials, community groups, faith-based organizations, or local business owners.

The PHNs practice involves the use of ?epidemiology?. Epidemiology? ?is the health science that studies the ?incidence? and ?prevalence? of disease in large populations. Incidence rates denote the emergence of a new illness. Prevalence rates reflect, in a given timeframe, the presence or pervasiveness of disease in a population compared to the overall health of the population at large. Epidemiologists aim to detect the source and cause of epidemics resulting from the pervasive presence of infectious diseases.. These scientists seek to understand patterns associated with the spread of communicable diseases and identify methods to minimize incidence or prevent outbreak. Programs in public health originate from data obtained through epidemiological research and focus on addressing infective agents, safeguarding biological or human hosts, and controlling the environment to prevent the spread of disease.

Aspects of the Public Health Nursing Role

? Advocates for the health of populations. ? Establishes credibility with the community. ? Concentrates on an aggregate or groups to improve the health of all. ? Seeks prevention of illness. ? Acts as a role model for leadership in provisions of health. ? Fosters community organization. ? Applies the ethical theory of utilitarianismmaking choices for the greater

good. ? Incorporates epidemiologic knowledge and methods. ? Conducts health assessment for entire populations for prevalence of disease,

risk factors, self-perceived health status, functional ability, and psychological stressors.

? Demonstrates versatility in dynamic collaborative environments. ? Exhibits cultural competence with diverse populations. ? Designs interventions for specific populations. ? Evaluates outcomes of interventions (Harkness & DeMarco, 2015; Joyce,

OBrien, Belew-LaDue, Dorjee, & Smith, 2014; Kulbok, Thatcher, Park, & Meszaros, 2012).

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The 10 Essential Public Health Services The Centers for Disease Control and Prevention (CDC) (n.d.) identifies three functions and 10 essential public health services (see Figure 1.1). Note the cyclical nature of Figure 1.1, indicating that assessment, policy development, and assurance are ongoing. System management features all the functions and essentials and incorporates the essential service of research. The discipline of nursing has the ability to be involved in every aspect of the wheel.

Figure 1.1

The 10 Essential Public Health Services

Note?. Adapted from The Public Health System & the 10 Essential Public Health Services, by the Centers for Disease Control and Prevention, 2017.

Assessment The assessment function incorporates the essential services of monitoring health status and diagnosis and investigation of community health problems and hazards (see Figure 1.1). PHNs are involved in data collection, community health assessment, and maintenance of data banks on population health statistics. The PHNs use the information to identify health risks and disparities, determine health service needs, and locate health care assets and resources to support health and quality of life improvements (Centers for Disease Control and Prevention [CDC], 2014). This health monitoring and identification process includes using technology, such as ?geographic informational systems (GIS)? to map the population for groups at higher risk than the overall population (CDC, 2014). The monitoring and diagnosis essential service of the assessment function involves timely identification and investigation of health threats; use of diagnostic resources, such as state public health laboratories; and development of plans to reduce health threats (CDC, 2014). The PHN is involved in epidemiologic investigations of disease outbreaks, patterns of infections, environmental hazards, chronic diseases, injuries, and any additional threat to the population, as well as developing plans for health care interventions (see Table 1.1).

Policy Development The development of public health policies address essential services and work to inform, educate, and empower the public about health concerns while mobilizing the community in support of key initiatives. (CDC, 2017b) (see Figure 1.1). The PHN builds knowledge and shapes attitudes about health through health education initiatives, informing the public of choices in health decision making, skills, and behaviors that contribute to a healthy quality of life. Health promotion and education is often supported through partnerships with employers, faith-based organizations, schools, and health care providers for implementation of initiatives and reinforcement of health information (CDC, 2014). Public service announcements are one mechanism in which media and marketing campaigns work to disseminate health information (see Table 1.1). Mobilization of community partnerships also aid in the identification of health problems and provide a source of both human and material resources. As public awareness increases, partnerships, coalitions, and alliances develop to support prevention, screening, and rehabilitation projects (CDC, 2014). The mobilization of partnerships serves as a foundation toward effective local public health governance. Policies and plans develop to support both individual and community efforts to protect health, further improve health, and prepare for emergency response to health threats (CDC, 2014). The PHN may be involved in the development of health policies, codes, regulations, and legislation that guide public health protections. PHN planning for health improvement occurs at both the local and state levels, including systematic alignment of resources for health improvement strategic planning.

Assurance

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? The assurance function encompasses enforcing laws, linking people to care providers, assuring a competent workforce, and evaluating program effectiveness (CDC, 2014). The enforcement of laws and regulations are for the protection of health and safety. The PHN is involved in public health emergencies requiring reinforcement, such as a quarantine, use of best practices to achieve compliance with health regulations, and education of the public regarding laws and regulations. Linking people in need of care to service providers involves the PHNs identification of barriers to care for various population aggregates and coordination of appropriate services to address, intervene, and overcome the barriers, including cultural, transportation, and language barriers. PHNs participate as members of the competent workforce by maintaining active licensure; using public health competencies, such as those from the QCC; and applying the concept of lifelong learning. PHNs assess, educate, and train other public health participants, such as students, volunteers, or lay community health workers. Measures for continuous quality improvements are adopted by PHNs while maintaining standards of care. PHNs seek opportunities for ongoing leadership development, cultural competence, and improvement of health disparities. PHNs evaluate the effectiveness, accessibility, and quality of individual and population-based public health services. This ongoing evaluation and review of effectiveness analyzes health status and service utilization data (CDC, 2014). This management of performance provides information toward allocation of resources and program revisions (CDC, 2014). The information should show how the needs of the population are met, which approaches are working, and what requires improvement.

System Management Research is an essential service contained throughout all three functions (CDC, 2014). This involves surveillance of the outcomes of research and development of links between public health practice and academic or research settings (CDC, 2014). Common research areas of focus include epidemiological studies, health policy analyses, and public health systems research (CDC, 2014). The PHN is involved in research activities, including initiation of research, participation of research by other entities, reporting results, and implementation of resulting evidence-based policies (see Table 1.1).

Table 1.1

Nursing Public Health Interventions

Intervention Definitions Examples

Assessment

? Surveillance ? Screening ? Case finding ? Investigation of disease

and health events

The continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice (World Health Organization [WHO], n.d.)

Screening used to detect risk factors for diseases or undiagnosed diseases

The systematic search for at risk persons

Track statistical data and clusters of health events for risk to the community and compliance with infection prevention/control measures

Tracking progress and spread of the Zika virus

Testing for tuberculosis in persons living with HIV

MRSA reported among several high school athletes

Policy Development

? Outreach ? Inform, educate,

empower ? Mobilize community

partnerships ? Develop policies

Providing information about health issues to the at risk groups, special interest populations, or the community at large

Public service announcement regarding influenza season and an upcoming flu immunization clinic

Check for Understanding

1. What aspects of national and global public health require enlarging the nurses perspective beyond the care of the individual and family?

2. How have nurses been instrumental in the creation of the current services in public health? 3. How do public health nurses meet the publics need for services?

Theories to Inform Public Health Nursing Practice

Assurance

? Referral and follow up ? Enforce laws ? Link to and/or provide

care ? Ensure competent

workforce ? Evaluate

Assistance to identify and access necessary resources to resolve health issues

Referral for counseling to victim of intimate partner violence and encouragement for follow-up appointments

Childhood immunization monitoring

System Management

? Incorporated within all of the above

? The research aspects of all of the above

Provides intersection of health, information and communication technologies, and research to employ new perspectives and innovative solutions to care for health problems

Epidemiological studies

Methods of data input and quality monitoring

The nursing profession adopts theories and conceptual frameworks from other disciplines, such as behavioral change models, systems theories including family systems theories, concepts of distributive? ?or? ?social justice?, and community organization models (see Table 1.2). When applying these concepts, the nurse seeks to discover the factors that influence the public to exchange unhealthy behaviors for healthier ones and seeks to determine how programs and revisions in community activities can promote and maintain health. Ethical care and ?general systems theory? are discussed next to demonstrate further applications to nursing. Table 1.2

Psychosocial Theoretical Approaches for Community Health Care

Ethical Care Ethical concepts relating to population health focus on the interdependence of people and what is of benefit to the population, while maintaining respect for the individual (Barrett et al., 2016). This social justice concept aligns well with the utilitarian ethical concept of doing the greatest good for the greatest number. The concept of distributive justice, a component of social? ?justice, emphasizes the need to equalize access to resources, assets, and services for all within a community (Devia et al., 2017). Social justice is at the foreground for combating health care

Concepts from Other Disciplines Application to Community/Public Health Nursing

Ethics, Distributive Justice, Social Justice First aid, food, and water distribution after a regional disaster

General Systems Theory, Family Systems Model

Assessment of the community

Behavioral Change Models:

? Transtheoretical Health Model ? Health Belief Model

Smoking cessation campaign and support groups

Community Organization Models:

? Mobilizing for Action Through Planning and Partnerships (MAPP)

? PRECEDE-PROCEED Model ? Community-Based Collaborative Action

Research (CBCAR)

Community and health care professionals collaborate to improve health through participatory decision making toward identification of key issues and strategies to develop and mobilize programs to achieve health goals

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inequities and health disparities. Every human has a fundamental right to health and well-being (WHO, 2017). Health inequities and disparities promote disease transmission, poverty, illiteracy, contaminated air and water, inadequate nutrition, and other aspects affecting a persons health. Nurses have knowledge, skills, and the duty to care in order to rebalance inequities and decrease health disparities. Nurses have access to numerous resources pertaining to nursing ethics and public health, including

? ANAs Code of Ethics for Nurses with Interpretive Statements (2015) ? ANAs The Nurses Role in Ethics and Human Rights (2016) ? ANAs Public Health Nursing: Scope and Standards of Practice (2015) ? ANAs Nursings Social Policy Statement (2010) ? The ICN Position Statement on Nurses and Human Rights (2006) ? The ICN Code of Ethics for Nurses (2012) ? CDCs Public Health Ethics website ? Principle of the Ethical Practice of Public Health (2002) ? WHO Guidelines on Ethical Issues in Public Health Surveillance (2017) ? Public Health Ethics: Cases Spanning the Globe (2016)

The Public Health Leadership Societys Principle of the Ethical Practice of Public Health (2002) contains 12 principles of ethical practice of public health, often referred to as the public health code of ethics (National Association of County and City Health Officials, n.d.). These principles are also used by the CDC, the APHA, and the National Association of County and City Health Officials.

Table 1.3

A Comparison of Clinical vs. Public Health Ethics Focus

Clinical Ethics Focus Public Health Ethics Focus

Individual autonomy is central; focus is on consent and privacy

Interdependence is central; autonomy can be restricted to protect the public

Treatment of individual disease Prevention of disease in

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